Consent to collect and exchange personal information
Purpose
Personal information that Trainers Choice Inc. (“Trainers Choice”) collects and discloses about you is used by The Manufacturers Insurance Company (“Manulife”), and/or OTIP/RAEO Benefits Inc. (“OTIP”) as the plan administrator of your group benefits plan and their service provider(s) for the purposes of assessing eligibility for your claims, administering the group benefits plan and for internal data management and data analytical purposes.
Authorization and consent
I authorize Trainers Choice to collect, use and disclose personal information concerning any claims submitted on my behalf with Manulife and/or OTIP and their service provider(s) for the above purposes.
I authorize Manulife and / or OTIP and their service provider(s) to:
- use my personal information for the above purposes.
- exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits, or other benefits programs, other organizations, or service providers working with such insurer and/or plan administrator or any of the foregoing, when relevant for the above purposes.
- where applicable, exchange personal information concerning any claims with any assignee of benefits payable and exchange personal information for the above purposes electronically or in any other manner.
I understand that personal information may be subject to disclosure to those authorized under applicable law.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original and may remain in effect for the continued administration of the group benefits plan.
If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my benefit plan sponsor, for that purpose.
If the patient is a person other than myself, I confirm that the patient has given their consent to provide their personal information for Trainer’s Choice, Manulife and/or OTIP and their service provider(s) to use and disclose their personal information as set out above.
Terms and Conditions of Benefit assignment
I hereby assign benefits payable for the eligible claims to Trainer’s Choice responsible for submitting my claims electronically to the group benefits plan and I authorize Manulife to issue payment directly to Trainer’s Choice. In the event my claim(s) is declined by Manulife and/or OTIP, I understand that I remain responsible for payment to Trainer’s Choice for any services rendered and/ or supplies provided.
I acknowledge and agree that any benefit payment made in accordance with this assignment will discharge Manulife and/or OTIP of its obligations with respect to that benefit payment. In the event the benefit payment is made to me, Manulife and/or OTIP will also be discharged of its obligation with respect to that benefit payment.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to Trainer’s Choice.
All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.
